Senior Center Activity Check-in Form
Please complete this form to check in for your activity at the senior center. Your information helps us ensure a safe and enjoyable experience for all participants.
Participant Full Name
*
First Name
Last Name
Date of Check-In
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Which activity are you checking in for today?
*
Please Select
Exercise Class
Arts & Crafts
Games & Social Hour
Educational Seminar
Music Group
Other
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address (optional)
example@example.com
Emergency Contact Name
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Do you have any allergies or health conditions our staff should be aware of?
Do you require any accessibility accommodations?
No accommodations needed
Wheelchair access
Hearing assistance
Other (please specify)
Time In
*
Hour Minutes
AM
PM
AM/PM Option
Time Out (to be completed when leaving)
Hour Minutes
AM
PM
AM/PM Option
Staff Notes (for office use only)
Check In
Should be Empty: